Targeted Case Manager; 4153-203-a - Brooklyn, United States - Catholic Charities Brooklyn and Queens

Catholic Charities Brooklyn and Queens

Verified Company

Brooklyn, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

For over 125 years, Catholic Charities Brooklyn and Queens has been providing quality social services to the neighborhoods of Brooklyn and Queens, and currently offers 160-plus programs and services for children, youth, adults, seniors, and those struggling with mental illness.

Targeted Case Management (TCM), specifically the COBRA HIV/AIDS TCM and the OMH TCM, plays a significant role in assisting eligible Medicaid individuals gain access to needed medical, behavioral, and social services.

With implementation of Health Homes, the Department of Health's Medicaid program, AIDS Institute, and the Office of Mental Health developed the following draft guiding principles and scenarios to help understand the role of TCMs relative to Health Homes.

These documents discuss TCMs and "converted" TCMs.

Converted TCMs are Medicaid enrolled targeted case management programs that, once approved by the State, are designated Health Homes, or participate in a State approved Health Home network.

STATEMENT OF THE JOB:

Under the direct supervision of the Clinical Director, the Targeted Case Manager (TCM) will play a pivotal role within the integrated care ecosystem of the Certified Community Behavioral Health Clinic (CCBHC).

Under the SAMHSA grant, the TCM will be part of a specialized team embedded in the CCBHC, targeting services for a high-risk behavioral health population being served under CCNS.

The TCM team will adhere to specific SAMHSA regulations and requirements regarding the frequency, scope and duration for working with clients under a Critical Time Intervention model.

The CCBHC is based on an initiative to expand Americans' access to mental health and addiction care in community-based settings.

CCBHCs are responsible for providing the following types of services:

crisis mental health services; screening, assessment and diagnosis, including risk assessment; patient-centered treatment planning; outpatient mental health and substance use services; primary care screening and monitoring of key health indicators/health risk; targeted case management; psychiatric rehabilitation services; peer support and family supports; intensive, community-based mental health care for members of the armed forces and veterans.

Under the CCBHC model, the Targeted Case Manager (TCM) will work in conjunction with the CCNS CCBHC clinics and will coordinate care across settings and providers to ensure seamless transitions for clients across the full spectrum of health services, including acute, chronic, and behavioral health needs.

Duties of the TCM focus on the integration of the care team to serve the client in any appropriate need-based area, including mental health, medical issues, social determinants of health, substance use issues, psychosocial needs, food insecurity, housing instability.

The TCM is responsible for high quality targeted case management services that will assist individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, and other services and supports.

In conjunction with interdisciplinary team, is accountable for engaging and retaining client in care, arranging for the continuous provision of services, supporting adherence to treatment recommendations, monitoring and evaluating client needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, and social and community services where appropriate through the creation of an individual plan of care.
Outreach via phone to clients between visits (check on selfcare, medication fills, treatment plan, schedules visits, tests/followup); monitors that the client completes postvisit followup (fill prescriptions, make appointments).
Conduct comprehensive assessments to develop a personcentered and recoveryoriented Care Plan.
Coordinate care across the spectrum of health services, including access to highquality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, entitlements/benefits and employment opportunities as necessary to facilitate wellness and recovery of the whole person.
In collaboration with interdisciplinary team, clients, their family and/or caregivers, and other service providers, develops, manages and coordinates a comprehensive individualized personcentered care plan that coordinates and integrates the continuum of medical, behavioral health services, rehabilitative, long term care and social service needs and clearly identifies the primary care physician/nurse practitioner, specialists, behavioral health care providers, care manager and other providers directly involved in the individual's care.
Ensure the availability of priority appointments for CCBHC clients to treatment services including physical, psychiatric, and substance abuse within their health provider network to avoid unnecessary, inappropriate utilization of emergency room and inpatient hospital services.
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